This paper provides a comprehensive overview of alcohol use disorder (AUD) as defined by the DSM-5, examining how the manual's updated criteria consolidate previous distinctions between alcohol abuse and alcohol dependence into a single, severity-scaled diagnosis. The paper discusses the prevalence of AUD in the United States, the eleven diagnostic criteria used to classify mild, moderate, and severe presentations, and the multifactorial etiology encompassing genetic, biological, psychological, and sociological influences. Treatment options covered include Alcoholics Anonymous, cognitive-behavioral therapy, family counseling, and pharmacological interventions such as Naltrexone, Disulfiram, and Acamprosate. Physical and psychological complications, including comorbid mood disorders and polysubstance use, are also addressed.
Substance use disorders, including alcohol use disorder, are defined in the most recent edition of the Diagnostic and Statistical Manual (DSM-5) by the presence of several time-dependent subjective and behavioral criteria. Diagnostic criteria vary depending on the substance being used or abused. Alcohol use disorder is among the most significant of these diagnoses, given the legality of alcohol and the prevalence of alcohol use in the general population.
According to the National Institutes of Health, the vast majority — upwards of 86% — of all people in the United States drink at least occasionally, with more than half drinking monthly (National Institute on Alcohol Abuse and Alcoholism, 2015). It is estimated that approximately seven percent of the adult population in the United States has an alcohol use disorder, representing more than 16 million people. Of those, only 1.3 million receive formal treatment in a specialized facility (National Institute on Alcohol Abuse and Alcoholism, 2015). Alcohol use represents a serious and costly burden to society, owing to the high mortality rates associated with alcohol use, including impaired driving.
The DSM-5 has revised the operational definitions of alcohol use disorder to simplify the criteria for diagnosis and to help professionals provide more timely and effective interventions, including counseling, cognitive-behavioral therapy, and pharmacological interventions. Among the most important updates from previous editions is the amalgamation of alcohol abuse and alcohol dependence into a single designation: alcohol use disorder. Rather than classifying abuse and dependence separately, the DSM-5 offers the ability to classify alcohol use disorder as mild, moderate, or severe based on the expression of specific criteria.
The criteria for alcohol use disorder include those related to subjective responses — such as desire and craving — as well as more measurable behavioral indicators and biological or physiological responses to withdrawal. Several of the criteria relate directly to the effects of alcohol on friendships and other social relationships, work performance, or physical safety. For example, a person might perform poorly or be absent from work directly due to alcohol use. Behavioral criteria also include time spent in alcohol-related activities and consuming larger quantities of alcohol over a longer period of time than was either desired or intended. Loss of friendships and other social problems may also serve as behavioral signs of alcohol use disorder. One of the diagnostic criteria is the cessation of participation in activities that once benefited the individual or brought pleasure, such as sports or social events.
A cornerstone of the diagnosis is the frequency of behavioral patterns; alcohol use disorder is qualified by recurrence and persistence, not by single isolated events or behaviors. Overall, there are eleven distinct criteria defining alcohol use disorder. According to the DSM-5, a person who expresses two or three of these criteria may be classified as having mild alcohol use disorder. A person expressing four or five symptoms would be classified with moderate alcohol use disorder, while persons exhibiting six or more symptoms would be classified as having severe alcohol use disorder.
As with other substance use disorders, alcohol use disorder is also qualified by the presence of tolerance — that is, increased resistance to the effects of alcohol leading to increased intake in order to achieve the desired effects. Another criterion is interference with obligations; getting into legal trouble may also be a related concern, although it is not an official feature of the DSM-5 criteria. Severe withdrawal symptoms may be present and are associated with the most severe stages of alcohol use disorder. Withdrawal can be characterized by nausea, sweating, tremors, and even hallucinations (American Psychological Association, 2015). Additional behavioral markers that may indicate alcohol use disorder include loss of appetite, uncharacteristically violent or aggressive behavior, neglect of personal hygiene, defensiveness when discussing alcoholism, and hiding alcohol (Burke, 2012).
Quantity of alcohol consumed is not part of the official diagnostic criteria according to the DSM-5. However, substance use organizations like the Substance Abuse and Mental Health Services Administration (SAMHSA, 2015) classify moderate, binge, and heavy drinking according to quantities consumed. These quantity guidelines are distinct from the DSM-5 diagnostic criteria and serve as supplementary tools that therapists may use when assessing or interviewing clients. SAMHSA (2015) defines moderate drinking as one to two drinks per day, and binge drinking as five or more drinks on the same occasion on at least one day in the past thirty days. Heavy drinking is defined as five or more drinks on the same occasion for five or more days in the past thirty days (SAMHSA, 2015). Some people experience blackouts, or lapses in memory, after binge or heavy drinking (Burke, 2012).
There is no single known cause of alcohol use disorder, although genetic, biological, psychological, and sociological factors may all be involved (American Psychological Association, 2015). Some individuals may be more prone to alcohol use disorder due to genetics, personality characteristics, and environmental variables ("Causes," n.d.). Environmental and situational variables range from poverty and social oppression to the experience of trauma and abuse. Moreover, these causal variables affect each person differently; some people are more susceptible to peer pressure than others, for example (American Psychological Association, 2015). There is no genetic test for alcohol use disorder, although genetics are most likely involved in its etiology.
"Physical health risks, suicide, and polysubstance use"
"Therapy, Alcoholics Anonymous, and pharmacological options"
Alcohol use disorder has recently been reclassified to combine the diagnostic criteria of alcohol dependence and alcohol abuse. Alcohol use disorder shares much in common with other substance use disorders, including those involving tobacco, narcotics, stimulants, or cannabis. While these disorders share common elements — and a person may be dependent on more than one substance simultaneously — each disorder presents unique challenges and requires unique approaches to treatment and care.
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